Variations in risk-adjusted cesarean delivery rates according to race and health insurance

Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients

OBJECTIVE

This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record.

STUDY DESIGN

A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model.

RESULTS

There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population.

CONCLUSION

Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity.

KEY POINTS

· Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor..

Inequalities in cesarean births between American Indian & Alaska Native people and White people

OBJECTIVE

To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors.

DATA SOURCES AND STUDY SETTING

We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017.

STUDY DESIGN

We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality.

DATA COLLECTION/EXTRACTION METHODS

Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate.

PRINCIPAL FINDINGS

After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0-34.8), 3.2 percentage points (95% CI: 1.8-4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie).

CONCLUSIONS

The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.

Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States

BACKGROUND

Racial and ethnic disparities in obstetrical and neonatal outcomes are prevalent in the United States. Such racial or ethnic disparities have also been documented in the prevalence of cesarean deliveries.

OBJECTIVE

We aimed to evaluate the impact of maternal education on racial or ethnic disparities in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States.

STUDY DESIGN

This is a retrospective analysis of the Centers for Disease Control and Prevention live births database (2016–2019). Nulliparous, term, singleton, vertex births from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. Pregnancies complicated by gestational or pregestational diabetes mellitus and hypertensive disorders were excluded. Data were analyzed on the basis of the level of maternal education (less than high school graduate, high school graduate, college graduate, and advanced degree). We compared the prevalence of cesarean deliveries among the different racial or ethnic groups within each education level using Pearson chi-square test with Bonferroni adjustment. Multivariate logistic regression was performed to assess the association between cesarean deliveries and maternal race/ethnicity, maternal education, and the interaction between maternal race or ethnicity and education level, while controlling for potential confounders. To demonstrate the effect of the interaction, separate logistic regression models with similar covariates were performed for each education level and for each race/ethnicity group. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios with 95% confidence intervals.

RESULTS

The overall prevalence of cesarean deliveries during the study period was 23.4% (695,214 of 2,969,207 births). All racial or ethnic minority groups had higher rates of cesarean deliveries than non-Hispanic White women (non-Hispanic Black, 27.4%; non-Hispanic Asian, 25.6%; Hispanic, 23.0%; and non-Hispanic White, 22.4%; [P<.001 for all comparisons]). Similar racial or ethnic differences in cesarean delivery rates were detected among all education levels. Higher levels of education were associated with a lower likelihood of cesarean delivery (adjusted odds ratio, 0.88; [95% confidence interval, 0.87–0.89]) in women with advanced degrees than in women who did not graduate from high school. However, although maternal education was associated with a protective effect in non-Hispanic White and non-Hispanic Asian women (adjusted odds ratio, 0.83 [95% confidence interval, 0.81–0.85] and adjusted odds ratio, 0.81 [95% confidence interval, 0.77–0.86], respectively, for women with advanced degrees), it had a smaller protective effect in non-Hispanic Black women (adjusted odds ratio, 0.93 [95% confidence interval, 0.89–0.97]) and no protective effect in Hispanic women (adjusted odds ratio, 0.98 [95% confidence interval, 0.96–1.01]).

CONCLUSION

We document a significant racial/ethnic disparity in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. Furthermore, our findings suggest that although a higher level of maternal education is associated with a lower likelihood of cesarean delivery, this protective effect varies among racial or ethnic groups. Further research is needed to investigate the underlying causes for this racial/ethnic disparity.

Term Singleton Vertex Cesarean Birth Rates in the Military Health System

Cesarean births have increased in the United States, accounting for approximately one-third of all births. There is concern that cesarean birth is overused, due to the wide variation in rates geographically and at different institutions within the same region. Despite the rising rate, there has not been an improvement in maternal or neonatal outcomes. Consequently, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published recommendations aimed at the safe prevention of primary cesarean births in 2014. The purpose of this project was to identify the term singleton vertex cesarean birth rates in the Military Health System's hospitals; to compare the Military Health System's rate of term singleton vertex cesarean birth to published benchmarks; and to compare term singleton vertex cesarean birth rates over time and among facilities within the Military Health System to determine whether variation existed. This was a retrospective review of aggregate data reported by the National Perinatal Information Center. Data were analyzed over 9 years at 2-year intervals from 2011 through 2019 inclusively. The Military Health System exceeded national benchmarks for term singleton vertex cesarean birth rates and had less variation over time and among facilities.

Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care

BACKGROUND

Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care.

OBJECTIVE

To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide.

RESEARCH DESIGN

Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care.

RESULTS

Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites.

CONCLUSIONS

There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

BACKGROUND

In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction.

METHODS

To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth.

RESULTS

Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth.

CONCLUSIONS

While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Elucidating the role of overweight and obesity in racial and ethnic disparities in cesarean delivery risk

PURPOSE

We aimed to quantify the extent to which overweight and obesity explain cesarean delivery risk among women of different racial and ethnic backgrounds.

METHODS

Using administrative records for 216,481 singleton, nulliparous births in New York City from 2008 to 2013, we calculated risk ratios, risk differences, and population attributable fractions for associations between body mass index (BMI) and cesarean, stratified by race and ethnicity.

RESULTS

The population attributable fraction (95% confidence interval) for BMI was 6.8% (6.2%-7.3%) among Asian, 10.9% (10.4%-11.4%) among White, 14.6% (13.7%-15.5%) among Hispanic, and 17.4% (16.2%-18.6%) among Black women. Although overweight and obesity were most prevalent among Black and Hispanic women, the risk gradient was strongest among Whites (adjusted risk ratio [95% CI] from 1.37 [1.33-1.41] for overweight to 2.23 [2.07-2.39] for class III obesity). Additional adjustment for gestational complications partially attenuated associations, and accounting for delivery hospital eliminated the stronger gradient among White women.

CONCLUSIONS

Prepregnancy overweight and obesity contribute proportionally more to cesarean risk among Black and Hispanic women because of higher prevalence compared to White or Asian women. Although preconception weight management is important to decrease cesarean risk, results encourage attention to clinical approaches in low-risk pregnancies to mitigate racial and ethnic perinatal disparities.

Metabolomic Pathways Predicting Labor Dystocia by Maternal Body Mass Index

Objectives  The purpose of this study was to evaluate the metabolic pathways activated in the serum of African-American women during late pregnancy that predicted term labor dystocia. Study Design  Matched case-control study ( n  = 97; 48 cases of term labor dystocia and 49 normal labor progression controls) with selection based on body mass index (BMI) at hospital admission and maternal age. Late pregnancy serum samples were analyzed using ultra-high-resolution metabolomics. Differentially expressed metabolic features and pathways between cases experiencing term labor dystocia and normal labor controls were evaluated in the total sample, among women who were obese at the time of labor (BMI ≥ 30 kg/m2), and among women who were not obese. Results  Labor dystocia was predicted by different metabolic pathways in late pregnancy serum among obese (androgen/estrogen biosynthesis) versus nonobese African-American women (fatty acid activation, steroid hormone biosynthesis, bile acid biosynthesis, glycosphingolipid metabolism). After adjusting for maternal BMI and age in the total sample, labor dystocia was predicted by tryptophan metabolic pathways in addition to C21 steroid hormone, glycosphingolipid, and androgen/estrogen metabolism. Conclusion  Metabolic pathways consistent with lipotoxicity, steroid hormone production, and tryptophan metabolism in late pregnancy serum were significantly associated with term labor dystocia in African-American women.

Successful versus unsuccessful instrumental deliveries-Predictors and obstetric outcomes

OBJECTIVE

The purpose of this study was to examine instrumental births in a multi-ethnic population to assess the factors associated with success and failure in instrumental births.

STUDY DESIGN

This was a large retrospective study of 7954 women that underwent either a successful or an unsuccessful instrumental delivery in a single centre over a 10 year period.

RESULTS

Logistic regression analysis showed that women with a BMI of more than 30, attempted Forceps delivery, having a prolonged second stage, Macrosomia (birth weight more than 4 kg) and a senior obstetrician performing the procedure increase the risk of a failed instrumental delivery. While age, ethnicity, type of anaesthesia, use of oxytocin or induction of labour did not provide a significant outcome. Results also showed that patients are likely to bleed more and neonates need admission in failed instrumental deliveries when compared to successful attempts.

CONCLUSION

This is one of a very few studies comparing a large cohort of successful instrumental births with unsuccessful attempts at an instrumental birth. The rate of failure has been difficult to reduce, and the analysis shows that many of the factors associated with failure are not modifiable in labour. We should consider studies with use of ultrasound assessment before application or consideration of instruments to facilitate birth. This will allow us to objectively come up with an algorithm to predict success or failure and consider if it is suitable to attempt an instrumental birth. Our data can be used to counsel women about the difficulty in predicting success and failure rate of instrumental births.

Health system factors and caesarean sections in Kosovo: a cross-sectional study

OBJECTIVE

To investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo.

DESIGN

Cross-sectional survey.

SETTING

Five largest public hospitals in Kosovo.

PARTICIPANTS

859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo.

OUTCOME MEASURES

The prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital.

RESULTS

Women with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90).

CONCLUSIONS

We found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities

BACKGROUND

Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade.

OBJECTIVE

To estimate trends and differences in obstetric quality measures by race/ethnicity.

RESEARCH DESIGN

We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated.

RESULTS

ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period.

CONCLUSIONS

Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

Paradox lost on the U.S.-Mexico border: U.S. Latinas and cesarean rates

BACKGROUND

We apply Intersectional Theory to examine how compounded disadvantage affects the odds of women having a cesarean in U.S.-Mexico border hospitals and in non-border hospitals. We define U.S. Latinas with compounded disadvantage as those who have neither a college education nor private health insurance.

RESULTS

Analyzing quantitative and qualitative data from Childbirth Connection's Listening to Mothers III Survey, we find that, consistent with the notion of the Latinx Health Paradox, compounded disadvantage serves as a protective buffer and decreases the odds of cesarean among women in non-border hospitals. However, the Latinx Health Paradox is absent on the border.

CONCLUSION

Our data show that women with compounded disadvantage who give birth on the border have significantly higher odds of a cesarean compared to women without such disadvantage. Further, women with compounded disadvantage who give birth in border hospitals report receiving insufficient prenatal, pregnancy, and postpartum information, providing a direction for future research to explain the border disparity in cesareans.

Progression of care among women who use a midwife for prenatal care: Who remains in midwife care?

BACKGROUND

Prenatal care provided by midwives provides a safe and cost-effective alternative to care provided by physicians. However, no studies have evaluated the frequency of women who leave midwifery care, in a hospital setting. Our study objectives were to measure the frequency of transfers of care to physicians, to describe the sociodemographic and pregnancy-related characteristics of women who transferred to the care of a physician during prenatal care and at delivery, and to assess correlates of these transfers.

METHODS

We used electronic medical records to perform a retrospective cohort study of women who delivered at The Ohio State University Wexner Medical Center (OSUWMC) and had at least one prenatal care visit within OSUWMC's network. We report descriptive findings, using proportions and means with standard deviations. We used logistic regression, with Firth's bias correction as necessary, to assess correlates of transferring to a physician during prenatal care and at delivery.

RESULTS

Most women who initiated prenatal care with a midwife remained in midwifery care throughout delivery, with 4.7% transferring to a physician during prenatal care, and an additional 21.4% transferring to a physician during delivery. After adjusting for pregnancy-related factors, the black race was statistically significantly associated with leaving midwifery care during prenatal care (adjusted odds ratio AOR 3.0 [95% CI 1.4-6.6]) and delivery (AOR 2.5 [95% CI 1.5-4.3]).

CONCLUSION

Findings indicate that most women remain in midwifery care throughout pregnancy, but raise important questions with respect to the possible role that race has in pregnancy care.

Perceptions of the effects of childbirth on sexuality among nulliparous individuals

BACKGROUND

Media representations of sexuality after childbirth depict vaginal birth as harmful and cesarean delivery as protective, although research does not support these depictions. The objective of the current study was to investigate perceptions of the effects of mode of delivery on sexuality.

METHODS

Nulliparous participants who were able to and interested in giving birth (N = 1428) completed an online survey about their preferences for mode of delivery and their perceptions of childbirth as they specifically relate to sexuality. Participants provided demographic information, rated how influential different sources of information about childbirth were, and completed the Attitudes Toward Women's Genitals Scale.

RESULTS

Up to half (16-48%), the participants agreed with different statements about vaginal birth as harmful to, and cesarean delivery as protective of, future sexuality. Participant characteristics that were independently predictive of endorsing these beliefs were: self-identifying as heterosexual, holding negative attitudes toward women's genitals, and reporting that reality media, nonreality media, and online media sources are influential sources of childbirth information. Participants who rated health care professionals as an influential source of information were less likely to endorse these beliefs.

CONCLUSION

Given that there is no clear evidence in the empirical literature to support the claim that vaginal births are harmful and cesarean delivery is protective to one's future sexual life, it is important to dispel the existing misconceptions. Various media sources likely play a role in the perpetuation of this misinformation.

Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

IMPORTANCE

The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown.

OBJECTIVE

To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status.

MAIN EXPOSURES

The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years.

MAIN OUTCOMES AND MEASURES

Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission.

RESULTS

The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women.

CONCLUSIONS AND RELEVANCE

In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

Caesarean sections and private insurance: systematic review and meta-analysis

OBJECTIVE

Financial incentives associated with private insurance may encourage healthcare providers to perform more caesarean sections. We therefore sought to determine the association of private insurance and odds of caesarean section.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and The Cochrane Library from the first year of records through August 2016.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of OR of caesarean section of privately insured as compared with publicly insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance. The prespecified secondary outcome was the crude OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance.

RESULTS

Eighteen articles describing 21 separate studies in 12.9 million women were included in this study. In a meta-analysis of 13 studies, the adjusted odds of delivery by caesarean section was 1.13 higher among privately insured women as compared with women with public insurance coverage (95% CI 1.07 to 1.18) with no relevant heterogeneity between studies (τ²=0.006). The meta-analysis of crude estimates from 12 studies revealed a somewhat more pronounced association (pooled OR 1.35, 95% CI 1.27 to 1.44) with no relevant heterogeneity between studies (τ²=0.011).

CONCLUSIONS

Caesarean sections are more likely to be performed in privately insured women as compared with women using public health insurance coverage. Although this effect is small on average and variable in its magnitude, it is present in all analyses we performed.

Malpractice Experience and the Incidence of Cesarean Delivery: A Physician-Level Longitudinal Analysis

This study examines the influence of malpractice claims on the practice behavior of a panel of obstetricians in Florida during the period 1992–1995 to determine whether physicians respond to malpractice events by performing more cesareans, consistent with the notion that cesarean sections are employed as “defensive medicine.” Findings indicate that clinical events resulting in claims that lead to substantial indemnity payments have a significant, modest effect on physician practice behavior: physicians experiencing those claims increase their risk-adjusted cesarean rates by about one percentage point. Malpractice experience does not appear to affect patient mix, but claims with large payouts may affect patient volume.

Investigating racial differences in risk factors for primary cesarean delivery

OBJECTIVE

The objective of the study was to investigate differences in sociodemographic, medical, and obstetric risk factors for primary cesarean delivery between black and white women.

STUDY DESIGN

We conducted a retrospective cohort study among 25,251 black and white women delivering a live, singleton infant with vertex presentation at a large, regional hospital between 2004 and 2010. Demographic and clinical data were derived from electronic hospital records. Differences in risk factors for primary cesarean delivery were analyzed using a modified Poisson regression approach stratified by race and parity.

RESULTS

Black and white women had a primary cesarean delivery rate of 24.7% and 22.2%, respectively (P < .001). Black women had an increased risk of cesarean delivery after adjusting for sociodemographic and clinical risk factors (adjusted relative risk [RR], 1.23; 95% confidence interval [CI], 1.17-1.29). Among nulliparas, labor induction had a greater effect on cesarean delivery for black women (adjusted RR, 1.32; 95% CI, 1.20-1.44) than for white women (adjusted RR, 1.13; 95% CI, 1.07-1.20). Among multiparas, labor induction reduced the risk of cesarean delivery for white women (adjusted RR, 0.63; 95% CI, 0.55-0.72), whereas no association was observed for black women (adjusted RR, 1.08; 95% CI, 0.92-1.28). Advanced maternal age was a stronger risk factor for black women (adjusted RR, 1.72; 95% CI, 1.43-2.08) than for white women (adjusted RR, 1.30; 95% CI, 1.11-1.52) among multiparas only. Among nulliparas, delivery at 37-38 weeks' gestation reduced the risk of cesarean delivery for black women (adjusted RR, 0.82; 95% CI, 0.73-0.92), whereas no association was observed for white women (adjusted RR, 0.96; 95% CI, 0.90-1.04).

CONCLUSION

Labor induction, among nulliparous women, and advanced maternal age, among multiparous women, are stronger risk factors for primary cesarean delivery for black women than for white women.

Geographic variation in cesarean delivery in the United States by payer

BACKGROUND

The rate of cesarean delivery in the United States is variable across geographic areas. The aims of this study are two-fold: (1) to determine whether the geographic variation in cesarean delivery rate is consistent for private insurance and Medicaid (2) to identify the patient, population, and market factors associated with cesarean rate and determine if these factors vary by payer.

METHODS

We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to measure the cesarean rate at the Core-Based Statistical Area (CBSA) level. We linked the hospitalization data to data from other national sources to measure population and market characteristics. We calculated unadjusted and risk-adjusted CBSA cesarean rates by payer. For the second aim, we estimated a hierarchical logistical model with the hospitalization as the unit of analysis to determine the factors associated with cesarean delivery.

RESULTS

The average CBSA cesarean rate for women with private insurance was higher (18.9 percent) than for women with Medicaid (16.4 percent). The factors predicting cesarean rate were largely consistent across payers, with the following exceptions: women under age 18 had a greater likelihood of cesarean section if they had Medicaid but had a greater likelihood of vaginal birth if they had private insurance; Asian and Native American women with private insurance had a greater likelihood of cesarean section but Asian and Native American women with Medicaid had a greater likelihood of vaginal birth. The percent African American in the population predicted increased cesarean rates for private insurance only; the number of acute care beds per capita predicted increased cesarean rate for women with Medicaid but not women with private insurance. Further we found the number of obstetricians/gynecologists per capita predicted increased cesarean rate for women with private insurance only, and the number of midwives per capita predicted increased vaginal birth rate for women with private insurance only.

CONCLUSIONS

Factors associated with geographic variation in cesarean delivery, a frequent and high-resource inpatient procedure, vary somewhat by payer. Using this information to identify areas for intervention is key to improving quality of care and reducing healthcare costs.

Disparities in cesarean delivery by ethnicity and nativity in New York city

Our objective was to examine differences in risk of cesarean delivery among diverse ethnic groups in New York City. Using cross-sectional New York City birth and hospitalization data from 1995 to 2003 (n = 961,381) we estimated risk ratios for ethnic groups relative to non-Hispanic whites and immigrant women relative to US-born women. Adjusting for insurance, pre-pregnancy weight, maternal age, education, parity, birthweight, gestational age, year, medical complications, and pregnancy complications, all ethnic groups except East Asian women were at an increased risk of cesarean delivery, with the highest risk among Hispanic Caribbean women [adjusted risk ratio (aRR) = 1.27, 95 % CI (confidence interval) = 1.24, 1.30] and African American women (aRR = 1.20, 95 % CI = 1.17, 1.23). Among Hispanic groups, immigrant status further increased adjusted risk of cesarean delivery; adjusted risk ratios for foreign-born women compared to US-born women of the same ethnic group were 1.27 for Mexican women (95 % CI = 1.05, 1.53), 1.23 for Hispanic Caribbean women (95 % CI = 1.20, 1.27), and 1.12 for Central/South American women (95 % CI = 1.04, 1.21). Similar patterns were found in subgroup analyses of low-risk women (term delivery and no pregnancy or medical complications) and primiparous women. We found evidence of disparities by ethnicity and nativity in cesarean delivery rates after adjusting for multiple risk factors. Efforts to reduce rates of cesarean delivery should address these disparities. Future research should explore potential explanations including hospital environment, provider bias, and patient preference.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts

BACKGROUND

Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts.

METHODS

Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research.

RESULTS

While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women.

CONCLUSIONS

Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.

Midwifery care at a freestanding birth center: a safe and effective alternative to conventional maternity care

OBJECTIVE

To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care.

DATA SOURCES/STUDY SETTING

Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions.

STUDY DESIGN

Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument.

DATA COLLECTION/EXTRACTION METHODS

Birth certificate data from 2005 to 2008.

PRINCIPAL FINDINGS

Women who receive birth center care are less likely to have a C-section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes.

CONCLUSIONS

For women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes.

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study

Background

Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center.

Methods

A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006–2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups.

Results

The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor.

Conclusions

Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.

Maternal racial origin and adverse pregnancy outcome: a cohort study

OBJECTIVE

To examine the association between maternal racial origin and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.

METHODS

This was a retrospective study in women with singleton pregnancies attending their first routine hospital visit at 11 + 0 to 13 + 6 weeks of gestation. Data on maternal characteristics, and medical and obstetric history were collected and pregnancy outcomes ascertained. Regression analysis was performed to examine the association between racial origin and adverse pregnancy outcomes including pre-eclampsia (PE), gestational hypertension (GH), gestational diabetes mellitus (GDM), preterm delivery (PTD), small-for-gestational age (SGA), large-for-gestational age (LGA), miscarriage, stillbirth and elective and emergency Cesarean section (CS).

RESULTS

The study population included 76 158 singleton pregnancies with a live fetus at 11 + 0 to 13 + 6 weeks. In addition to maternal characteristics and obstetric history, Afro-Caribbean racial origin was associated with increased risk for miscarriage, stillbirth, PE, GH, spontaneous PTD, GDM, SGA and CS. In women of South Asian racial origin there was increased risk for PE, GDM, SGA and CS, and East Asian race contributed to the prediction of GDM and SGA.

CONCLUSION

Maternal racial origin should be combined with other maternal characteristics and obstetric history when calculating an individualized adjusted risk for adverse pregnancy outcome.

Predictors of cesarean delivery for periviable neonates

OBJECTIVE

To test for racial or ethnic disparities or both in periviable cesarean delivery and describe sociodemographic and clinical characteristics associated with periviable cesarean delivery.

METHODS

This was a retrospective cohort study of state-level maternal and neonatal hospital discharge data linked to vital statistics data for deliveries occurring between 23 0/7 and 24 6/7 [corrected] weeks of gestation in California, Missouri, and Pennsylvania from 1995 to 2005 (N=8,290).

RESULTS

Approximately 79% of the population was aged 18-35 years, and almost half were nulliparous. Almost 20% of the women were African American, 36.4% were Hispanic, and 33.6% were white. Overall, 33.6% of periviable neonates were delivered by cesarean. In multivariable analyses adjusting for sociodemographic and clinical characteristics, cesarean delivery did not differ among African American and Hispanic women compared with white women (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.76-1.05; and OR 0.95, 95% CI 0.83-1.09, respectively). Women presenting with preterm labor were significantly less likely to undergo cesarean delivery (OR 0.84, 95% CI 0.73-0.96), whereas women presenting with preterm premature rupture of membranes (OR 1.29, 95% CI 1.14-1.45) or abruption (OR 2.43, 95% CI 2.09-2.81) were more likely to have cesarean deliveries. The strongest predictor of periviable cesarean delivery was pregnancy-induced hypertension (OR 15.6.4, 95% CI 12.3-19.7).

CONCLUSION

Unlike disparities observed at later gestational ages, cesarean delivery did not differ by race and ethnicity among this periviable cohort. Instead, medical indications such as pregnancy-induced hypertension, preterm premature rupture of membranes, or abruption were associated with a higher likelihood of cesarean delivery. Periviable deliveries represent a subset of deliveries, wherein race and ethnicity do not influence mode of delivery; the acuity of the clinical encounter dictates the course of care.

Health disparities: a primer for public health social workers

In 2001, the U.S. Department of Health and Human Services published Healthy People 2010, which identified objectives to guide health promotion and to eliminate health disparities. Since 2001, much research has been published documenting racial and ethnic disparities in healthcare. Although progress has been made in eliminating the disparities, ongoing work by public health social workers, researchers, and policy analysts is needed. This paper focuses on racial and ethnic health disparities, why they exist, where they can be found, and some of the key health/medical conditions identified by the U.S. Department of Health and Human Services to receive attention. Finally, there is a discussion of what policy, professional and community education, and research can to do to eliminate racial and ethnic disparities in healthcare.

Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants

Wide disparities in obstetric outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality, and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities because of sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetric disparities, with an eye toward potential etiologies, thereby improving our ability to target appropriate solutions.

Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates

We sought to examine racial/ethnic differences in deliveries by caesarean section (CS) over time, particularly among women at low risk for this procedure. To do so, we conducted a retrospective cohort study at the University of California, San Francisco, a tertiary care academic centre. Births occurring between 1980 and 2001 were included in the analyses. Women with multiple gestations, fetuses in other than the cephalic presentation or with other known contraindications to vaginal birth were excluded. A total of 28 493 African American, Asian, Latina and White women were studied. Risk-adjusted models were created to explore differences in CS risk by race/ethnicity. We also performed analyses of subgroups of women at relatively low risk of CS, and explored changes in observed disparities over time. The overall CS rate was 15.8%. The absolute rate was highest among Latinas (16.7%) and lowest among Asians (14.7%). After adjustment for known risk factors, African American women had a 1.48 times greater odds of having a CS than did White women [95% confidence interval (CI) 1.31, 1.68], and Latina women had a 1.19 times greater odds [95% CI 1.05, 1.34]. Stepwise adjustment for confounders showed that this variation is not entirely explained by known risk factors. These differences exist even for women at low risk of CS, and have persisted over time. We conclude that racial and ethnic disparities in CS delivery exist, even among women presumed to be at lower risk of CS; rates have not improved with time. Disparities in risk-adjusted CS should be considered as a quality metric for obstetric care, whether at the national, state, hospital or provider level.

Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section

BACKGROUND

Since the 1990s, nationwide rates of vaginal birth after cesarean section (VBAC) have decreased sharply and rates of cesarean section have increased sharply. Both trends are consistent with clinical behavior aimed at reducing obstetricians' exposure to malpractice litigation.

OBJECTIVE

To estimate the effects of malpractice pressure on rates of VBAC and cesarean section.

RESEARCH DESIGN, SUBJECTS, MEASURES

We used state-level longitudinal mixed-effects regression models to examine data from the Natality Detail File on births in the United States (1991-2003). Malpractice pressure was measured by liability insurance premiums and tort reforms. Outcome measures were rates of VBAC, cesarean section, and primary cesarean section.

RESULTS

Malpractice premiums were positively associated with rates of cesarean section (beta = 0.15, P = 0.02) and primary cesarean section (beta = 0.16, P = 0.009), and negatively associated with VBAC rates (beta = -0.35, P = 0.01). These estimates imply that a $10,000 decrease in premiums for obstetrician-gynecologists would be associated with an increase of 0.35 percentage points (1.45%) in the VBAC rate and decreases of 0.15 and 0.16 percentage points (0.7% and 1.18%) in the rates of cesarean section and primary cesarean section, respectively; this would correspond to approximately 1600 more VBACs, 6000 fewer cesarean sections, and 3600 fewer primary cesarean sections nationwide in 2003. Two types of tort reform-caps on noneconomic damages and pretrial screening panels-were associated with lower rates of cesarean section and higher rates of VBAC.

CONCLUSIONS

The liability environment influences choice of delivery method in obstetrics. The effects are not large, but reduced litigation pressure would likely lead to decreases in the total number cesarean sections and total delivery costs.

Determinants of caesarean section in Lebanon: geographical differences

This study, based on the Lebanese National Perinatal Survey which included 5231 women, examined the relations between the caesarean section (CS) rate and the characteristics of mothers, children, antenatal care and maternity units in two geographical zones of Lebanon (Beirut-Mount Lebanon and the rest of the country) and then looked at geographical variations. This analysis concerned 3846 women with singleton pregnancies and livebirths at low risk of CS, after exclusion of women with a previous CS, non-cephalic fetal presentations, or delivery before 37 weeks' gestation. The principal end point was caesarean delivery. The relations between the factors studied and CS were estimated by odds ratios (OR), both crude and adjusted, using logistic regression. The rate of CS was higher in the Beirut-Mount Lebanon zone than elsewhere (13.4% vs. 7.6%). After adjustment, several factors remained associated with caesarean delivery in each zone. Common factors were primiparity, gestational age > or = 41 weeks and antenatal hospitalisation. Factors identified only in the Beirut-Mount Lebanon zone were obstetric history and insurance coverage, whereas for the other zones we only found major risk factors for obstetric disease: maternal age > or = 35 years, number of antenatal consultations > or = 4 and birthweight < or = 2500 g. The multivariable analysis of the overall population, adjusting for zone of delivery and other variables, shows that zone was one of the principal factors associated with the risk of caesarean delivery in Lebanon (OR = 1.80 [95% CI 1.09, 2.95]). In conclusion, the CS rates in Lebanon were high, with geographical differences that were associated with access to care and with obstetric practices.

Prediction of a caesarean delivery by labour and delivery nurses

The predictive accuracy of a nurse on labour and delivery to foretell the route of delivery is unknown. Registered nurses directly involved in managing women's labour predicted the route of delivery on 199 women between September 2005 and September 2006. The sensitivity to identify women who subsequently would deliver by caesarean was 26% (95% CI 13-42%); positive predictive value of 38% (20-39%) and likelihood ratio of 2.6 (1.3-7.5). Experience did not improve the predictive accuracy.

Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery

OBJECTIVE

This study was undertaken to assess whether racial differences in the risk of cesarean delivery result from differing practices of their caregivers or the hospitals at which they deliver.

STUDY DESIGN

A retrospective cohort study was performed using the Perinatal Database of the Memorial Health Care System. Logistic regression was used to estimate the risk of primary cesarean delivery among patients eligible for labor. The contribution of hospital and physician level cluster correlation was evaluated using fixed and random effects regression models.

RESULTS

Compared with white patients, black and Hispanic patients were 75% and 22% more likely to undergo primary cesarean delivery. Further adjustment for hospital and physician level cluster correlation resulted in persistently increased risks of primary cesarean delivery in black (54%) and Hispanic patients (12%).

CONCLUSION

Hospital site of delivery and individual physician practices do not fully explain racial differences in the risk of primary cesarean delivery.

A Framework for the Development of MaternalQuality of Care Indicators

BACKGROUND

In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality.

OBJECTIVE

To develop potential indicators for the assessment of maternal health care quality.

MATERIALS AND METHODS

A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible.

RESULTS

Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits).

CONCLUSIONS

These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.

Overview of current state of research on pregnancy outcomes in minority populations

Pregnancy outcomes improved significantly over the 20th century in the United States but currently vary widely between women of different ethnic and racial backgrounds. The current health disparities that exist are based, in part, only on differences in socioeconomic status or education. There is wide variability in pregnancy outcomes within specific subgroups of women. Disparities may be due to underlying differences in health before pregnancy, differences in community norms, and individual lifestyle choices and to differences in health care delivery systems. Areas for needed research and promising new models of care are reviewed.

Clinical case mix adjustment of cesarean delivery rates in U.S. military hospitals, 2002

OBJECTIVE

To assess whether significant variations in observed cesarean rates in U.S. military hospitals may be attributed to differences in clinical case mix.

METHODS

Hospital discharge records for births in U.S. military hospitals in 2002 were grouped into mutually exclusive clinical strata to calculate predicted cesarean rates for subgroups defined by maternal race, health plan, hospital location, delivery volume, teaching status, and neonatal intensive care unit (NICU) status. The 95% confidence interval (CI) around each standardized ratio (SR) of the observed-to-predicted cesarean rate was used to assess statistical significance.

RESULTS

Observed cesarean rates were significantly higher than predicted rates for small hospitals (23.1% and 20.4%, respectively, SR 1.13, 95% CI 1.08-1.19), teaching hospitals (23.7% and 22.5%, respectively, SR 1.05, 95% CI 1.02-1.08), black women (25.1% and 22.8%, respectively, SR 1.10, 95% CI 1.05-1.14), and other minorities (22.7%, and 21.6%, respectively, SR 1.05, 95% CI 1.01-1.09). No significant differences between observed and predicted cesarean rates were found across hospital locations or NICU status. Significant differences found for non-managed care beneficiaries were attributed to teaching status of the hospitals in which they delivered.

CONCLUSION

Clinical case mix does not adequately account for the relatively high rates of cesarean delivery observed for small hospitals and teaching hospitals and among black women in the study population. Further study is recommended to identify additional clinical and nonclinical factors that should be considered when comparing performance across institutions, health plans, or individual providers.

Association of Acculturation with Cesarean Section among Latinas

OBJECTIVES

Examine the association of acculturation and cesarean section after adjusting for clinical and non-clinical factors that could influence clinical discretion in performing the surgery.

METHODS

A sample of 2102 low-risk, low-income primarily Mexican Latinas in San Diego County was divided into two groups: primiparas and multiparas. For each parity group, logistic regression was used to assess the association of acculturation and cesarean section.

RESULTS

Among multiparous Latinas, the risk of cesarean section for highly acculturated women exceeded the risk for the less-acculturated women, but the result was reverse for primiparous women. The adjusted relative odds of cesarean section were twice as high [OR 2.1, 95%CI 1.1-4.1] for multiparous US-born Latinas relative to multiparous Spanish-speaking women born in Mexico. While for primiparous women this same comparison showed US-born Latinas to be approximately half as likely to have a cesarean delivery [OR 0.4, 95%CI 0.2-0.7].

CONCLUSIONS

In order to reduce the chances of unnecessary cesarean sections among Latinas, the role of acculturation in women who have and have not already given birth needs to be investigated further.

Explaining Source of Payment Differences in U.S. Cesarean Rates: Why do Privately Insured Mothers Receive More Cesareans than Mothers Who are not Privately Insured?

The difference in the risk-adjusted cesarean rates of mothers who are and who are not privately insured is divided into components attributable to the following four factors: the practice style of the physician attending the birth, the closeness of the physician-mother relationship, individual nonclinical factors, and the direct influence of private insurance on the physician's treatment decision. Estimates from two expansive, complementary data sets indicate that the most of the differential is attributable to the first two factors, particularly the pairing of privately insured mothers with physicians who are inclined to perform cesareans. There is some evidence that these pairings are not incidental but the result of firm (and possibly consumer) choices.

Factors predictive of failed operative vaginal delivery

OBJECTIVE

The purpose of this study was to determine what factors are independently associated with an increased likelihood of failed operative vaginal delivery.

STUDY DESIGN

We conducted a population-based case-control study evaluating maternal, pregnancy, provider, care setting, and fetal factors associated with failed operative vaginal delivery. Subjects were identified using Washington state birth certificates for infants born between 1992 and 2001. Cases (n = 1750) were live-born singletons with both labored cesarean delivery and an operative vaginal delivery ("failure") coded on the birth certificate. Controls (n = 3500), frequency matched by delivery year to the cases, were randomly selected from among singletons undergoing a successful operative vaginal delivery. Odds ratios (OR) and associated 95% CI, estimated with Mantel-Haenszel methods, measured the association between case status and potential risk factors.

RESULTS

Failed operative vaginal delivery was associated with increased maternal age, African American race, higher body mass index (BMI), diabetes, polyhydramnios, induction of labor, dysfunctional labor, and prolonged labor. Case compared with control mothers were more likely to deliver a low-birth weight or macrosomic infant.

CONCLUSION

Identification of maternal and fetal factors associated with failed operative vaginal delivery may enable providers to better counsel patients, and allow improved planning and allocation of surgical resources.

Explaining the association of maternal age with Cesarean delivery for nulliparous and parous women

METHOD

We used data on 6,805 live births from the National Maternal and Infant Health Survey to examine the positive association between maternal age and Cesarean delivery.

RESULTS

For parous women, the unadjusted risk ratio [RR] for Cesarean, comparing 35 year olds with 20 year olds, was estimated to be 1.40 [95% confidence limits (CL)=1.18, 1.65]; this association disappeared upon adjustment for obstetrical predictors and other factors (adjusted RR=1.04; 95% CL=0.80, 1.35). In contrast, for nulliparous women, the unadjusted risk ratio was 2.16 (95% CL=1.78, 2.63) and remained substantial upon adjustment (RR=1.74; 95% CL=1.25, 2.43).

CONCLUSION

These results, along with baseline risk information, suggest that older nulliparous women and their obstetricians should be the target of future efforts to control Cesarean rates.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

Reliability of birth certificate data: a multi-hospital comparison to medical records information

OBJECTIVE

To examine the reliability of birth certificate data and determine if reliability differs between teaching and nonteaching hospitals.

METHODS

We compared information from birth certificates and medical records in 33,616 women admitted for labor and delivery in 1993-95 to 20 hospitals in Northeast Ohio. Analyses determined the agreement for 36 common data elements, and the sensitivity, specificity, and positive and negative predictive values of birth certificate data, using medical record data as a "gold standard."

RESULTS

Sensitivity and positive predictive value varied widely (9-100% and 2-100%, respectively), as did agreement, which was "almost perfect" for measures of prior obstetrical history, delivery type, and infant Apgar score (K = 0.854-0.969) and "substantial" for several other variables (e.g., tobacco use (K = 0.766), gestational age (K = 0.726), prenatal care (K = 0.671)). However, agreement was only "slight" to "moderate" for most maternal risk factors and comorbidities (K = 0.085-0.545) and for several complications of pregnancy and/or labor and delivery (K = 0.285-0.734). Overall agreement was similar in teaching (mean K = 0.51) and nonteaching (K = 0.52) hospitals. Although agreement in teaching and nonteaching hospitals varied for some variables, no systematic differences were seen across types of variables.

CONCLUSIONS

Our findings indicate that the reliability of birth certificate data vary for specific elements. Researchers and health policymakers need to be cognizant of the potential limitations of specific data elements.